Review Article

When a Sibling Has Autism: Narrative

Review of Interventions for Typically
Developing Siblings
Karishma Godara1 , Vaibhav Patil2 and Nisha Phakey3

ABSTRACT Asperger’s syndrome, and pervasive devel- take on additional responsibilities such
opmental disorders.2 It can be identified as household chores.11 This, however, can
Being a typically developing sibling to a
child with autism spectrum disorder (ASD- by the early onset of impairments in social be a source of emotional distress.10 More-
Sib) can be associated with several behav- communication and repetitive, restricted, over, the need for long-term specialized
ioral and mental health problems. With this or unusual sensory-motor behaviors.2,3 Such therapy makes autism costly for parents.12
understanding, researchers are beginning behavioral repertoires a child with ASD pos- It is also likely that parents who have to
to focus on sibling-oriented interventions. sess can be an overwhelming experience care for a child with autism might not be
This review seeks to evaluate the current lit- and might impact each member of the fam- able to spend much time with the other
erature on such interventions. We searched ily. This can affect various domains of their sibling and much of their attention is
digital databases and identified eight
lives, including mental health, physical inadvertently concentrated on the child
relevant studies. The sample (n = 247) had an
health, finances, housekeeping, quality of with autism.10 Thus, having a sibling with
age range of 4–16 years. The outcomes were
generally positive, with improvements in relationships, and lifestyle.4,5 ASD can, directly and indirectly, impact
different facets of ASD-Sibs. Results differed The behavior and caregiving load might the ASD-Sibs’ mental health7 and quality
due to varied intervention styles, outcome particularly cause additional problems of life.13 Consequently, the relationship
variables, methods, and samples. Our find- with the typically developing brothers between the typically developing siblings
ings highlight the potential for improvement and sisters. Siblings of children with any (TDS) and ASD siblings might also be
in ASD-Sib’s knowledge of autism and their disability, including ASD, are more prone strained.14–16 This, in turn, can also affect
psychological functioning and hence call for to develop emotional, adjustment, and the prognosis and social functioning of
further research with robust methods.
behavioral problems than their peers.5–9 the ASD child.
Keywords: Autism spectrum disorder, Barak-Levy et al. found that children who Though the siblings’ role in the treat-
typically developing siblings, Asperger’s have siblings with autism have lower par- ment and training process of children
syndrome, sibling-oriented interventions ticipation in peer activities, poor relations with ASD has been well acknowledged

A
utism Spectrum Disorders (ASD) are with friends, and poorer school perfor- and evaluated in the literature,14,15,17
a set of varied groups of conditions mance and that such children have higher empirical literature focusing on inter-
affecting about one in every 100 scores on measures of responsibility.10 To ventions directed towards the TDS,
children.1 ASD includes autistic disorder, support their parents, the siblings often despite their well-acknowledged need,

1
National Drug-Dependence Treatment Centre and Dept. of Psychiatry, All India Institute of Medical Sciences, New Delhi, India. 2Dept. of Psychiatry & NDDTC, All
India Institute of Medical Sciences, New Delhi, India. 3Dept. of Clinical Psychology, Amity University, Punjab, India.

HOW TO CITE THIS ARTICLE: Godara K, Patil V and Phakey N. When a Sibling Has Autism: Narrative Review of Interventions for
Typically Developing Siblings. Indian J Psychol Med. 2023;XX:1–7.

Address for correspondence: Vaibhav Patil, Dept. of Psychiatry and National Drug Submitted: 15 Oct. 2022
Dependence Treatment Centre, All India Institute of Medical Sciences, Ansari Accepted: 26 Apr. 2023
Nagar, New Delhi 110029, India. Published Online: xxxx
E-mail: [email protected]

Copyright © The Author(s) 2023

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative ACCESS THIS ARTICLE ONLINE
Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/)
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which permits non-Commercial use, reproduction and distribution of the work without further permission
provided the original work is attributed as specified on the Sage and Open Access pages (https:// DOI: 10.1177/02537176231176404
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Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2023 1

Godara et al.
is still in infancy. To our knowledge, this was on the TDS of children with autism. Outcome Measures
body of research has not been synthe- Four studies kept the inclusion criteria
sized. Hence, this narrative review aimed strictly as ASD,19,21,24,25 though the other The interventions in the reviewed articles
to understand the impact of interven- four studies, albeit focusing on ASD, focused on various psychosocial vari-
tions directed toward ASD-Sibs. included related disorders or co-morbidi- ables such as knowledge about autism,
ties too20,22,23,26 (Table 1). social support, coping, adjustment, self-
Methods concept, depression, and anxiety
Features of Intervention (Table 3). Some studies also employed
Search Strategies qualitative measures. For example, in
Table 2 summarizes the key char- the study of Cooke and Semmens (2011),
We searched PubMed and Web of Science acteristics of the interventions and the siblings were asked to make a poster
for the 2000 to 2023 period. The key- critical analysis in terms of the outcomes. listing everything they knew about
words employed were “intervention,” Support groups were the most common autism (and/or Asperger syndrome). In
“support group,” “siblings,” “brothers,” type of intervention utilized,18,19,21–23,25 another study, a semi-structured ques-
“sisters,” “children with ASD,” “children whereas one used psychoeducation.24 tionnaire concerning the sibling’s views
with autism,” and “children with “PDD.” The main foci of the studies selected were: was used to elicit information regarding
We included studies that (a) were empir- enhancing knowledge and/or under- participants’ concerns about the sib-
ical, (b) were published in the English standing of autism,18,19,21,24,27,28 improving lings’ behavior, their consequences, and
language, and (c) reported interventions mental health, managing symptoms of participants’ expectation from the inter-
addressed to TDS of children with autism anxiety and depression,21,23,25 and manag- vention.22 Four studies also evaluated the
(or related neuro-disorders). Studies ing emotional/behavioral problems.24,25 experiences of the participants via quali-
were excluded that (a) focused on TDS- A few studies also focused on improving tative feedback. 19,22,26,27
mediated interventions with autism (or the siblings’ coping, adjustment, and
related disorders) or (b) were theoretical problem-solving skills.18,22,24,25 The least Summary of Findings
or used secondary data. focused variables were self-concept,18
social support,22 and improving sibling All included studies employed a pre-and-
Results relationships.20 post design. Smith and Perry26 evaluated
The sessions varied from 6 to 10, lasting the effectiveness of a support group on
Overview of Studies 1 to 2 hours weekly.19,21–24,26,27 All the inter- 26 siblings of children with autism. The
ventions were delivered in person19,21–27 self-concept of the siblings (P < 0.005)
Our initial search yielded 726 titles.
and one utilized the audio conferencing and their knowledge regarding autism
After removing duplicates (n = 98), two
mode.22 (P < 0.01) improved significantly.
authors (KG and VP) separately screened
and reviewed abstracts (n = 638). The dis-
crepancies were resolved by discussion
among all three authors. After remov- FIGURE 1.
ing non-related articles (n = 616) that Flow Diagram Displaying the Selection of Articles.
did not meet the objective of this paper,
we reviewed potentially relevant articles
(n = 12). Out of these, eight did not meet
the inclusion articles. Four studies were
included via manual search. Finally, we
identified eight studies (Figure 1).
Included studies were published from
2005 to 2020. Five studies utilized a quasi-
experimental design,18–22 whereas two
employed an experimental design, i.e.,
with a control arm.23,24 Only one was a
randomized control trial (RCT)25 (Table 1).

Sample Characteristics
A total of 247 (age = 4-16) TDS, older or
younger than the sibling with autism,
participated in these studies. Most
studies (n = 6) comprised only siblings,
whereas two also included parents. Four
studies were conducted in Europe,19,20,22,24
three in North America,21,25,26 and one
was from Australia.23 The focus broadly

2 Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2023

 Review Article
TABLE 1.

Findings Regarding Research Design and Study Population.

Age Range
Author and Year Design and Related Variables N (Finally Analysed) (Years) Target Condition
Smith & Perry, Design: Quasi-experiment 26 siblings (14 girls) 6-16 Autism or a related disorder (PDD, Rett
2005 Data collection points: two (pre- and (older and younger); (M = 10.63, Disorder, developmental delay)
post-intervention) Responses from parents SD = 2.13)
Follow-up period: two weeks were also utilized
Cooke & Design: Quasi-experiment, 12 (8 girls) (younger and 8–12 Autism or Asperger Syndrome
Semmens, Data collection points: two (pre and older) Responses from
2011 post-intervention). parents were also utilized
Follow-up period: two weeks
Granat et al., Design: Quasi-experiment design, 54 (33 girls) (younger 8–12 Autism, Aspergers, ADHD, physically
2011 Data collection points: two (pre and and older) disability, intellectually disabled,
post-intervention)
Follow-up period: two weeks
Kryzak et al., Design: Quasi-experiment design, 15 (6 girls) 4–14 ASD (PDD not otherwise specified,
2014 Data collection points: two (pre and autism, Asperger’s, or autism spectrum
post-intervention) diagnoses)
Gettings et al., Design: Quasi Exp/ Longitudinal 6 (5 girls) (younger) 8–13 ASD (as well as comorbidities in the ASD-
2015 Data collection points: two (pre and Responses from parents affected siblings such as ADHD, mood
post-intervention) were also included disorder, OCD, Down Syndrome, ODD,
Follow-up period: three to six months enuresis, visual impairment, harmful use
of cannabis, anxiety disorder/phobia)
Roberts et al., Design: Experimental 42 (25 girls) (older and 7.5–12.5 ASD (however, some had Angelman’s
2015 Data collection points: three (baseline, younger) (M = 9.3, Syndrome, Down Syndrome,
post-intervention, and follow-up) SD = 1.38) Phelan-McDermid Syndrome, Global
Follow-up period: three months Developmental Delay, PDD,
ID, and Optic Nerve Hypoplasia)
Bruzous et al, Design: Experimental (with control arm) 38 Age 6–15 ASD
2017 Data collection points: two (pre and (M = 10.75)
post-intervention)
Jones et al., Design: RCT 54 (control arm = 34, 5–14 Autism
2020 Data collection points: two (pre and support group = 24)
post-intervention) (30 girls)
ADHD, Attention Deficit Hyperactivity Disorder; ASD, autism spectrum disorder; ID, intellectual disability; M, mean; OCD, obsessive compulsive disorder; ODD, oppositional
defiant disorder; PDD, pervasive developmental disorder; RCT, randomized controlled trial; SD, standard deviation.

TABLE 2.

Characteristics of Interventions and Outcomes.

Study: Author, Year Intervention Details Outcomes Strengths and Limitations
Smith & Perry, 2005 Intervention type: Support Group. Greater knowledge of siblings of Strengths: Qualitative data indicated
Number of Sessions: eight (weekly) autism; improvement in overall that the participating children enjoyed
Main components: increasing knowledge self-concept following group their experience.
about autism and related developmental participation; no significant Limitation: Small sample size,
disorders, enhancing coping skills, difference was observed in lack of control group, no follow-up
enhancing self-concept, the siblings’ feelings of anger/ assessment was done.
Mode: In-person resentment (coping measure)
Cooke & Semmens, 2011 Intervention type: Support Group Enhanced knowledge of autism Strengths: In-depth data provides
Number of sessions: eight, two hours quite rich insight into the
(weekly) (last two sessions were kept as understanding and experiences of
outings) children regarding ASD.
Main components: knowledge of ASD, Limitations: Small sample size lack of
Mode: In-person control group; the outcome measures
could not ascertain the increase or
decrease reliably

(Table 2 continued)

Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2023 3

Godara et al.
(Table 2 continued)

Study: Author, Year Intervention Details Outcomes Strengths and Limitations

Granat et al., 2011 Intervention type: Group Intervention. Significant improvement in TD Strengths: Comparison with siblings
Number of sessions: six (two hours) siblings’ correct denomination of children with other disabilities
(weekly) of their sibling’s disability; throw light on the similarities and
Main components: enhancing knowledge, improvement in explanation of the dissimilarities in their experiences.
problem-solving skills sibling’s disorder which; there was Limitations: self-selected sample;
Delivered by: Clinical Staff from the no marked improvement in problem- lack of randomization
outpatient rehabilitation centre solving strategies in the siblings of
Mode: In-person children with ASD.
Kryzak et al., 2014 Intervention type: Support Group Improvement in siblings’ self- Strengths: Focus on the mental health
Number of sessions: 7 (2 hours) reported depression and anxiety; of siblings.
Main components: improvement in siblings’ adjustment Limitations: Lack of randomization,
Delivered by: licensed and credentialed and peer network small sample size
professionals (special education)
psychology doctoral fellows, and student
volunteers (undergraduate and masters
from related fields).
Mode: In-person
Gettings et al., 2015 Intervention type: Support Group Number of The intervention showed improved Strengths: Use of audio-conferencing;
sessions: 8 sessions (1 hour) communication among family high attendance (indicative of good
Main components: group cohesion, members, as well as improvement in engagement)
psychoeducation, problem-solving, and siblings’ social networks. Limitations: Extremely small sample
instillation of hope size
Mode: Audio-conferencing
Roberts et al., 2015 Intervention type: Manual-based Cognitive The treatment group showed Strengths: The presence of a control
Behavioural Support Group improvement in emotional and arm,
Number of sessions: 6 weekly, 2 hour behavioural difficulties, improved Limitations: Lack of randomization
Main components: self-esteem
Siblings’ perceived social support, problem-
solving skills, self-esteem, adaptive coping
skills, and sibling relationships
Delivered by: Provisionally registered
clinical psychologist (supervised by a
clinical psychologist)
Mode: In-person
Bruzous et al, 2017 Intervention type: Significant increase in knowledge Strengths: the presence of a control
Psychoeducational Group Sessions about autism post-intervention; arm; enrolled participants spanning a
Number of sessions: 8 /wk (90 mins) significant reduction in adjustment wide age range
Main components: psychoeducation, difficulties and emotional or/and included in the intervention groups,
emotional education, cognitive behavioural difficulties post- thus making it possible to take
restructuring, relaxation techniques, intervention into consideration developmental
problem-solving, social skills training, and issues when evaluating the group’s
self-acceptance efficacy.
Mode: In-person Limitations: lack of randomization
Jones et al., 2020 Intervention type: Support group Marked improvements in coping Strengths: use of randomization
Number of sessions: 10 weekly (2 hours) skills and externalizing behavior in Limitations: A lot of baseline
Main components: learning about the the intervention group were observed questionnaires were not returned to
group and each other, sharing feelings and, the team, hence generating a lot of
education, helping and problem-solving, missing data. Though, the missing
and reflection. data were random.
Delivered by: masters and Ph.D. students
(trained and supervised by authors)
in psychology with a background in
implementing social skills intervention for
children with ASD
Mode: In-person
ASD, autism spectrum disorder; PhD, Doctor of Philosophy; Wk, Week.

However, there was no improvement knowledge of the autism spectrum. The 15 siblings from 14 families. The study
in feelings of resentment or anger. findings suggested improved knowl- observed a marked improvement in
A noted limitation was the lack of a edge; however, the study lacked a control the depression and anxiety levels of the
control group.26 Cooke and Semmens19 group. Also, quantitative results have not siblings. Moreover, the peer networks of
utilized an 8-session workshop-based been reported. Cooke and Semmens19 and the siblings also improved.21
support group on 12 siblings of children Kryzak et al.21 developed and evaluated a In their hybrid intervention, Gettings
with ASD to assess the improvement in 7-week Support and Skills Program on et al.22 administered four face-to-face and
4 Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2023
 Review Article
TABLE 3.
cognitive restructuring, psychoeduca-
tion, relaxation, problem-solving, and
Measurement Instrument Used in the Studies. self-acceptance, yielded positive results.
Domain Instrument (Abbreviation) Study Findings revealed marked improvement
Knowledge about autism Sibling Knowledge Interview (SKI) Granat et al., 2011 in knowledge of autism and a significant
Autism sibling knowledge Kryzak et al., 2015 reduction in adjustment difficulties in
the experimental group.24 In their RCT,
Knowledge of autism syndrome Brouzos et al., 2017
Jones et al.25 assigned 98 participants to
Mental health, behavioral, Achenbach child behavior checklist Jones et al., 2020;
and emotional problems Smith & Perry, 2005
a support group and an attention-only
group to improve the mental health
The strengths and difficulties Brouzos et al., 2017;
questionnaire (SDQ) Gettings et al., 2015 of the TDS. The support group (n = 24)
was administered a 10-week interven-
The strengths and difficulties Roberts et al., 2015
questionnaire—Parent Version tion. The findings showed significant
Child behavior checklist (filled by a Jones et al., 2020
improvement in the coping skills and
parent). management of externalizing symptoms
The brief developmental behaviour Roberts et al., 2015 in the intervention group as compared to
checklist the control.25
Children’s depression inventory (CDI) Jones et al., 2020;
Kryzak et al., 2015 Discussion
Revised children’s manifest anxiety Jones et al., 2020; ASD in a child can significantly and
scale Kryzak et al., 2015
detrimentally affect family members, par-
Profile of neuropsychiatric symptoms Gettings et al., 2015 ticularly the other siblings.4,5,13–15 While
Autism severity Childhood Autism Rating Scale (CARS) Jones et al., 2020 some literature demonstrates positive
Self-esteem and concept Piers-Harris children’s self-concept Smith & Perry, 2005 experiences of ASD-Sibs,29 they might also
scale face adverse outcomes such as decreased
The Rosenberg Self-Esteem Scale Roberts et al., 2015 parental attention10; increase in nega-
(RSES; Rosenberg, 1989). tive life events (e.g., parents divorcing)30;
Sibling relationship The Sibling Relationship Questionnaire Granat et al., 2011; having to handle repetitive, unpredict-
(SRQ) Roberts et al., 2015 able, and aggressive behaviors of siblings,
Quality of life Paediatric Quality of Life Inventory Gettings et al., 2015 and elevated responsibilities.29 These
Support The Social Support Scale for Children Roberts et al., 2015 issues can increase stress and mental
(SSSC) health issues, including greater emo-
Support (self-developed questions). Jones et al., 2020 tional and/or behavioral problems and
Coping The Self-report Coping Scale (SRCS) Roberts et al., 2015 symptoms of anxiety and depression.21,29
Coping/adjustment scale Brouzos et al., 2017; Despite these well-documented poten-
Smith & Perry, 2005 tial risks for the siblings, there is limited
Children’s coping strategies checklist Jones et al., 2020 evidence-based literature focusing on
ameliorating these adverse outcomes.
This review synthesized the current
literature19,21–27 focusing on the interven-
four telemedicine sessions to six siblings intervention to 36 siblings of children tions for TDS of children with ASD. The
and their parents. The authors developed with various disabilities, particularly commonly studied interventions are
support group sessions that improved autism and other related disorders such support groups and psychoeducation.
communication between the siblings as attention deficit hyperactivity disor- Most studies comprised only siblings,
and with other family members as well. der (ADHD), global developmental delay, while a few studies also included parents
Additionally their knowledge improved etc. Findings revealed fewer behavioral for the intervention. Support groups
with psychoeducation, reducing their and emotional difficulties in the siblings’ aimed at providing the siblings social
concerns regarding their siblings, and group receiving the intervention. The support, along with psychoeducation
coping mechanisms improved, too. The positive results were sustained at three- to improve the knowledge of disability.
main strengths of the study were month follow-up.23 Though most interventions were deliv-
qualitative inquiry as well as the use Brouzos et al.24 developed and ered face to face, Gettings et al.22 found
of audio-conferencing. However, the examined the effectiveness of a psycho- audioconferencing an acceptable, feasi-
results are not generalizable, given the educational intervention on 38 siblings ble, and effective method of facilitating
small size.22 Roberts et al.23 used an exper- of children with ASD, intending to sibling support groups. The findings were
imental design to evaluate the SibwokrS improve their psychosocial adjustment/ generally positive, and most studies
program, i.e., a manual-based cognitive- coping and knowledge about autism. The showed marked improvement in knowl-
behavioral program that spanned six eight-week program, encompassing com- edge of autism followed by various facets
weeks. The authors administered the ponents such as emotional education, such as adjustment, coping, emotional

Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2023 5

Godara et al.
difficulties, problem-solving, self-con- educational levels, which might have an 9. Smith LO and Elder JH. Siblings and
cepts, and sibling relationships and in additional burden on the families. There family environments of persons with
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intervention studies focusing on sup- symptoms of the child to ascertain the
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disabilities such as pediatric cancer, dia- is for the sibling. Such insights might Weinstock M. Adjustment characteris-
betes, ADHD, and meningitis have also warrant tailor-made therapy. Lastly, tics of healthy siblings of children with
shown promising potential.31,32 Providing there is an urgent need for such interven- autism. J Family Stud 2010; 16(2): 155–164.
interventions in such a population may tion studies in low and middle-income 11. Dyke P, Mulroy S, and Leonard H. Siblings
help identify those who require addi- counties, and further interventions can of children with disabilities: challenges
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Declaration of Conflicting Interests disorder in India: a scoping review. Int Rev
Nevertheless, these findings should be
Psychiatry 2021; 33: 81–112.
interpreted cautiously, given the small The authors declared no potential conflicts of
13. Ferreira Marciano AR and Scheuer CI.
number of studies conducted and the interest with respect to the research, authorship,
and/or publication of this article. Quality of life in siblings of autistic
weak methodologies, namely lack of patients. Rev Bras Psiquiatr Sao Paulo Braz
control groups, lack of sufficient power Funding 1999 2005; 27: 67–69.
(i.e., small sample-size), and varied The authors received no financial support for the
14. Oppenheim-Leaf ML, Leaf JB, Dozier C,
inclusion criteria in terms of including research, authorship, and/or publication of this et al. Teaching typically developing
multiple disorders. Interventions in such article. children to promote social play with their
siblings with autism. Res Autism Spectr
populations should be family-centered,
ORCID iDs Disord 2012; 6: 777–791.
and thus, parents and/or caretakers can
15. Shivers CM and Plavnick JB. Sibling
be involved, which was lacking in most Karishma Godara https://orcid.org/0000-
0001-5229-7772 involvement in interventions for
studies. Studies were also lacking in the individuals with autism spectrum
Vaibhav Patil https://orcid.org/0000-0002-
use of measures to assess the impact of 2204-8625 disorders: a systematic review. J Autism
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